Field of the Invention
Methodologies, systems, and apparatuses for performing Medical Code-based decision-making related to matching a given medical identified element against one or more of a set of known or reference medical identified elements is disclosed herein.
Brief Description of Related Art
Fraudulent and erroneous medical claims are a serious problem, causing an estimated tens of billions of dollars in annual losses to insurance companies and governmental agencies.
The current system of medical claims processing, management, payment and reconciliation involves multiple stages of manual processes and workflows which are augmented by automated accounting and documentation systems. However, individual insurance companies maintain a vast number of clinicians and disparate automated systems which are prone to varying degrees of limitations inherent to human dependent systems run buy independent companies. The deficiencies within the current systems has created an industry of commercial insurance and government Recovery Audit Contractors (RAC's), whose payments are based on similar human review by clinicians and legal experts whose ultimate benefit is the sharing of recovered payment.
Given this fact and the natural incentive for RAC's to focus on high cost claims, there remains a significant number of un-recouped improper payments made, which now exceeds $24 billion per year for CMS claims alone as based on the Office of Management and Budget (OMB) estimates.